JAMA：近距离放疗可能增加老年乳腺癌患者术后并发症

5月2日，刊登在《美国医学会杂志》（Journal of American Medical Association）上的一项研究披露，在罹患浸润性乳腺癌并接受了肿块切除手术的老年妇女中，与全乳房照射（WBI）相比，近距离放射治疗可能导致手术后并发症的增加，以及乳房长期保全的可能性下降，但两者在总体存活率上并没有差别。

近距离放射疗法是一种用一个植入性放射源来进行放疗的手段，而且它已经被用于治疗各种恶性肿瘤。在近些年中，早期乳腺癌进行肿块切除术后施行乳腺近距离放疗的人数已经有了大幅的增加，尽管还缺乏将其与标准化的WBI的功效比较的随机试验数据。

休斯敦市得克萨斯大学MD Anderson癌症中心博士Grace L. Smith及其同事们开展了一项研究，旨在比较近距离放疗与WBI两种方式对术后中老年病人的并发症、乳房长期保全的可能性及存活率的效果。这一研究包括了92735名年龄在67岁或以上的妇女，她们在2003~2007年间被诊断出患有乳腺癌，并一直随访至2008年。在肿块切除后，6952名患者接受了近距离放疗，85783名患者接受了WBI。

研究人员发现，近距离放疗可能增加感染风险及非感染性术后综合征的发病几率。到术后1年时，接受近距离放疗的1126名（16.20%）患者曾有皮肤或软组织感染，而接受WBI的患者中出现这种情况的有8860人（10.33%）。 “类似地，到术后1年的时候，1132名（16.25%）接受近距离放疗的人经历了非感染性的术后并发症，而在接受WBI治疗的人中，这一数字为7721人（9.00%）。”Smith指出。

最后，研究人员得出结论：“鉴于乳腺癌的高发病率以及近来乳腺近距离放疗应用人数的快速增加，这些研究发现有相当大的潜在公共卫生意义。尽管这些结果还有待在其他环境中进行验证，但它们也提示在研究环境之外，人们应谨慎对待乳腺近距离放疗的广泛使用。”

doi:10.1001/jama.2012.3481
PMC:
PMID:

Association Between Treatment With Brachytherapy vs Whole-Breast Irradiation and Subsequent Mastectomy, Complications, and Survival Among Older Women With Invasive Breast CancerBrachytherapy vs Whole Breast Irradiation

Grace L. Smith, MD, PhD, MPH; Ying Xu, MD, MS; Thomas A. Buchholz, MD; Sharon H. Giordano, MD, MPH; Jing Jiang, MS; Ya-Chen Tina Shih, PhD; Benjamin D. Smith, MD

Context Brachytherapy is a radiation treatment that uses an implanted radioactive source. In recent years, use of breast brachytherapy after lumpectomy for early breast cancer has increased substantially despite a lack of randomized trial data comparing its effectiveness with standard whole-breast irradiation (WBI). Because results of long-term randomized trials will not be reported for years, detailed analysis of clinical outcomes in a nonrandomized setting is warranted. Objective To compare the likelihood of breast preservation, complications, and survival for brachytherapy vs WBI among a nationwide cohort of older women with breast cancer with fee-for-service Medicare. Design Retrospective population-based cohort study of 92 735 women aged 67 years or older with incident invasive breast cancer, diagnosed between 2003 and 2007 and followed up through 2008. After lumpectomy 6952 patients were treated with brachytherapy vs 85 783 with WBI. Main Outcome Measures Cumulative incidence and adjusted risk of subsequent mastectomy (an indicator of failure to preserve the breast) and death were compared using the log-rank test and proportional hazards models. Odds of postoperative infectious and noninfectious complications within 1 year were compared using the χ2 test and logistic models. Cumulative incidences of long-term complications were compared using the log-rank test. Results Five-year incidence of subsequent mastectomy was higher in women treated with brachytherapy (3.95%; 95% CI, 3.19%-4.88%) vs WBI (2.18%; 95% CI, 2.04%-2.33%; P < .001) and persisted after multivariate adjustment (hazard ratio [HR], 2.19; 95% CI, 1.84-2.61, P < .001). Brachytherapy was associated with more frequent infectious (16.20%; 95% CI, 15.34%-17.08% vs 10.33%; 95% CI, 10.13%-10.53%; P < .001; adjusted odds ratio [OR], 1.76; 1.64-1.88) and noninfectious (16.25%; 95% CI, 15.39%-17.14% vs 9.00%; 95% CI, 8.81%-9.19%; P < .001; adjusted OR, 2.03; 95% CI, 1.89-2.17) postoperative complications; and higher 5-year incidence of breast pain (14.55%, 95% CI, 13.39%-15.80% vs 11.92%; 95% CI, 11.63%-12.21%), fat necrosis (8.26%; 95% CI, 7.27-9.38 vs 4.05%; 95% CI, 3.87%-4.24%), and rib fracture (4.53%; 95% CI, 3.63%-5.64% vs 3.62%; 95% CI, 3.44%-3.82%; P ≤ .01 for all). Five-year overall survival was 87.66% (95% CI, 85.94%-89.18%) in patients treated with brachytherapy vs 87.04% (95% CI, 86.69%-87.39%) in patients treated with WBI (adjusted HR, 0.94; 95% CI, 0.84-1.05; P = .26). Conclusion In a cohort of older women with breast cancer, treatment with brachytherapy compared with WBI was associated with worse long-term breast preservation and increased complications but no difference in survival.